Treatment of Child Gratification Disorder

Objectives Gratification disorder is a group of self-stimulatory behaviors tending to form a habit. These normal behaviors are common and have various differential diagnoses, including epilepsy. Hence, misdiagnosis may lead to performing unnecessary workups and treatments. In this article, we systematically reviewed available treatment options for gratification disorder. Materials & Methods We systematically searched Scopus, MEDLINE, and Embase for related articles published from the beginning to 12th May 2021. We followed the search strategy in all electronic databases using keywords [“Self-gratification” AND “treatment”], [“child” AND “masturbation” AND “treatment”], [“Pediatric” AND “masturbation” AND “treatment”], [“infantile” AND “masturbation” AND “treatment”], and [“Benign” AND “Infantile” AND “Dyskinesia” AND “treatment”]. Results The primary search yielded 241 studies. Five studies fulfilled the inclusion criteria and were used in the systematic review. None of the studies provided a good level of evidence. These studies indicated that behavioral therapy, escitalopram, and aripiprazole could be considered treatment options. Conclusion Although pediatricians are familiar with gratification behaviors, their optimal management is overlooked. In addition to parental education and behavioral therapy, escitalopram and aripiprazole can be used as treatment options for this issue. We need to perform well-designed randomized controlled trials to obtain adequate evidence on the efficacy of these measures.


Introduction
Infantile and pediatric self-gratification is a benign phenomenon. Gratification disorder, also known as "infantile masturbation" or "benign idiopathic infantile dyskinesia," comprises a group of selfstimulatory behaviors with a tendency to form a habit (1)(2)(3)(4). These movements are often considered "disorders" because they are normal behaviors in early childhood (5,6). Although masturbation or self-stimulation of the genitalia is typical human behavior, little has been published on gratification disorder (masturbation) in early childhood (1,7).
Misdiagnosis is more probable when there is no apparent genital manipulation, and movements are described as staring, shaking, and moving limbs for minutes (1). Misdiagnosis may result in unnecessary workups and antiepileptic treatments (8)(9)(10)(11).
Masturbation is a non-openly discussed taboo, especially in African societies. Its occurrence in infancy may lead to procedures to control libido and future sexual behaviors, such as female genital cutting (8,12). Educating and counseling the parents are often the only suggested measures as gratification in infants is usually benign and tends to resolve spontaneously by two years of age (2,13). Besides, attempts to stop this behavior are not helpful and may even reinforce it (14). Recurrent daily friction in the perineal area may result in irritation. In addition, parents may know this habit as a disease and feel embarrassed if it occurs in public (15,16).

Sometimes it may result in useless investigations
and non-appropriate therapeutic measures. In addition, in some societies, such behaviors are considered a stigma and may be annoying to parents. This study aimed to perform a systematic review to examine proper treatments and family management based on available literature.

Materials & Methods
This study utilized a systematic literature search based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Availability of Data and Material
Data sharing does not apply to this article.

Results
The primary search yielded 241 studies. Five studies met the inclusion/exclusion criteria and were used in the systematic review (20-24) (Fig.   1). Table 1 shows a summary of these studies.
None of the studies provided a good level of evidence. The summary of related studies indicated that behavioral therapy, escitalopram, and aripiprazole could be possible treatments for this disorder (20)(21)(22)(23)(24). Two studies, including one prospective cohort study of 54 patients diagnosed with self-gratification habits, recommended that behavioral therapy could be used for the beneficial management of childhood masturbation (20,21).
Two other studies, as case reports, showed that medications such as escitalopram and aripiprazole are effective for treating child gratification (22,23). In another case series, two management steps   A prospective cohort study of 54 patients diagnosed with self-gratification habits Sixteen (29.63%) children were referred for behavioral therapy and all of them responded well in next one year.

Small sample size 2b
Franić/2011/Croatia [15] A case report of a 14-month girl with infantile masturbation The therapeutic plan was conceived at two levels. The first one was behavioral modification of the child, which was done by distraction of attention during attacks. The second goal was to diminish her mother's level of anxiety.
Case report 4 Fleisher/1990/USA [16] Case series of five girls, 7 to 27 months of age, with masturbatory posturing

Discussion
This systematic review aimed to examine the management of self-gratification or masturbatory habits. Although these paroxysmal behaviors are prevalent among children, their true prevalence is not addressed in scientific papers (20,21,23,24). A study suggested several diagnostic criteria,